Care Transition Support
In the immediate period following hospital discharge, many ambulatory elderly patients emerge from the hospital in a frail and vulnerable condition. Often they are confused about and/or non-compliant with post-discharge instructions. Due to bed-confinement, and poor oral intake, they are prone to complications such as falls, dehydration, and exacerbation of secondary medical conditions. These patients are at High Risk for Readmission ( HRRA).
Housecall Doctors clinicians provide prompt, comprehensive post-discharge care in the patient’s home. We ensure continuity and continued access to care in the vulnerable post-discharge period. Through collaboration and information-sharing with other relevant stakeholders, we facilitate effective care transition management for HRRA patients who need timely post-discharge visits to ensure compliance, fill gaps in care, coordinate resources, and facilitate the patient’s return into the ambulatory care track. As a result, partner institutions achieve a significant reduction in readmissions within 30 days to avoid readmission penalties and improve DRG performance.
We welcome inquiries from prospective institutional partners to discuss further the benefits of our post-discharge care transition service.